"Now," he pauses, before addressing another. "Stop for a
second. What's wrong? It didn't loop around."

And yet another tip: "Look at the way you started out,"
Brown says. "You have to cross your hands." The students
nod eagerly and stitch again.

In a smaller operating room across the hall, a urologist is
practicing tying knots as well. But the monofilament nylon
he's looping and pulling is several feet away from his
hands. As he works, the surgeon is looking at a 3-D camera
image of the operative field, where mechanical silver hands
are gently threading a suture. In this operating theater,
a robotic assistant is "closing" on the patient.

Both scenarios are part of the training mission at the
Johns Hopkins-U.S. Surgical Minimally Invasive Surgical
Training Center (MISTC), which provides lab sessions for
inexperienced surgeons, as well as tutorials in
cutting-edge medical technology such as robotic-assisted
surgery.

"On the one hand, we are teaching techniques taught since
the Egyptian time period: Young surgeons learn how to tie
knots before they work on a person," notes Brown, MISTC
director of education. "We are also training future
surgeons in future techniques."

Third-year Hopkins medical students hone their suturing
techniques in the MISTC lab.

Launched a little over a year ago with $3.2 million in
funding from U.S. Surgical Corporation, the lab at Blalock
12 has served over 1,500 Hopkins medical students,
residents, and surgeons, as well as visiting physicians and
members of medical associations attending lectures.

A suite of rooms on the 12th floor, MISTC (pronounced
mystic) offers an Internet-linked lecture hall, surgeon's
scrub room, two state-of-the-art operating theaters, and
other surgery prep rooms. Among the center's goals: to
provide training that can reduce time spent in the
operating room at Hopkins and other teaching hospitals, and
to give surgeons simulated surgical environments in which
to practice with evolving technology and instruments.

Paul W. Flint, Hopkins professor of
otolaryngology and MISTC co-director, plans to use the
robotic system in head and neck surgeries: "Any new
technology has associated with it potential complications,"
Flint says. "This helps to remove that component. It takes
some of the training out of the operating room."

On a cold afternoon in January, the third-year medical
students first gather in the lab's lecture hall, perusing
hand-outs that detail various surgical sutures -- Lembert
stitch and whip stitch -- as well as illustrations of
sponge forceps, towel clips, needle drivers, and other
surgical instruments.

Brett Nelson says he's benefited from the new lab's
approach for novice surgeons. "It is needed. Oftentimes we
don't get all the hands-on experience we want in the OR,"
says Nelson. "It gives us the opportunity to practice, and
not on patients."

For many decades, Hopkins offered such a surgical lab
course, first developed by Hopkins surgeons at the turn of
the 20th century. The course continued into the late 1990s,
closing down due to financial constraints, including the
costs associated with animal subjects. Brown, who stepped
in to the void to develop the new course, says, "There is a
huge tradition of training in surgery here at Hopkins. A
lot of medical schools [have] copied us."

Blalock 12 is in fact rich with the the spirit of medical
innovation. The building is named for Hopkins surgeon
Alfred Blalock, and the 12th floor housed his research
labs. Blalock, along with Hopkins pediatrician Helen
Taussig and surgical assistant Vivien Thomas, developed a
medical procedure in the 1940s to correct a congenital
heart defect in children, resolving what was known as the
"blue baby" syndrome in which the heart did not pump
sufficient blood to the lungs. Such surgery was previously
deemed too risky.

Decades before Blalock's contributions, noted Johns Hopkins
physicians were making pioneering contributions to the
world of surgery -- from William Halsted's successful
implementation of the first radical mastectomy in the late
1800s, to Walter Dandy's daring removal of brain tumors in
the mid-1920s. In more modern times, Hopkins surgeon
Patrick Walsh has dramatically altered the outcome of
prostate cancer surgery with his nerve-sparing
prostatectomy.

Professor Phillip Rand Brown guides his students in the
art of making precise surgical sutures. Brown is
enthusiastic about the range of opportunity offered by
MISTC. "On the one hand, we are teaching techniques taught
since the Egyptian time period. We are also training future
surgeons in future techniques."

"You cannot work here without being aware of that
heritage," Brown says. Such history, not surprisingly, has
laid the groundwork for ever-developing medical innovations
at Hopkins. MISTC leaders hope that future innovation will
become a hallmark of the lab.

"Aside from training surgeons, we are involved in research
and development," Brown adds. "Not to be arrogant, but we
want to strive to be in a leadership role in shaping
patient care in the future."

Through various short courses, surgeons and students can
tap a broad spectrum of surgical training, using inanimate
objects, such as rubber bands, as well as lab animals and
cadavers. New surgical techniques and tools can be tested
here. "It puts us on the cutting edge," notes David
Alexander, MISTC lab administrator, and administrator of
General Pediatric Surgery.

Robot-assisted surgery, for example, is being used in
Hopkins operating rooms and elsewhere by surgeons
conducting laparoscopic procedures in general surgery, and
urology, cardiac, and transplant surgeries, and it's being
tested for use in other specialties, such as
otolaryngology, neurosurgery, and gynecology.

The system here, known as the da Vinci Surgical System,
utilizes a $1 million machine Hopkins leases from its
developer, Intuitive Surgical Corp. There are two such
machines at Hopkins, including the one in the MISTC lab and
another in the Weinberg OR. Hopkins surgeons, nurses, and
surgical technicians have trained in the MISTC lab, though
medical students aren't yet using the robot. The lab itself
is one of only five in the country that offer such training
with robot-assisted surgery.

The da Vinci system does not approach the status of
autonomous robotic surgeon. It's more like a super-
high-tech instrument: The surgeon peers into a gray console
-- much like the replay console used by referees during
televised football games. A spidery array of robotic arms
is positioned over the patient.

Those robotic arms are attached to laparoscopic instruments
that are inserted through small incisions in the patient.
Therein lies the difference from traditional laparoscopic
surgery, in which surgeons rely on open-and-close clamps on
the tips of the long, thin instruments they manipulate with
their hands.

Using the robotic system, surgeons instead manipulate
handlike controls in the console. Their hand and wrist
motions are then translated into corresponding, precise
movements of versatile "hands" on the end of the
laparoscopic instruments. These robotic-assisted
"endowrist" instruments give surgeons a wider degree of
motion and provide more precise movement during suturing
and cutting of tissue, according to Intuitive Corp., which
runs courses for visiting doctors at MISTC. The robotic
system also helps reduce hand fatigue and tremors during
surgery.

Peering into a console, Paul Flint, co-director
of the MISTC lab at Hopkins, can observe an operative field
and manipulate hand-like controls (below, right) that
remotely activate robotic "hands" on the end of
laparoscopic instruments (below, left). Visiting
urologist Daniel Holmes, of Kansas City, Missouri, looks
on.

Urologist Daniel Holmes of St. Luke's Hospital in Kansas
City, Missouri, was training at MISTC in late January,
removing a kidney from a pig using the da Vinci system.
"There's nothing better than a surgeon's hands during
surgery," he says. "But with laparoscopic surgery we can't
use our hands anyway. We use instruments. [The robotic
system] is more like what we can do with our hands. And the
benefit is, you don't have a big incision."

The potential for robot-assisted laparoscopic surgery is
vast: If the console can be seven feet away, it could also
work many miles away, using images carried over phone lines
or the Internet. Through telesurgury, surgeons in the
United States, for example, can operate on someone across
the globe. One such surgery was conducted in fall 2001 by
surgeons at Mt. Sinai Medical Center in New York, who
removed the gall bladder of a 68-year-old woman in
Strasbourg, France.

"One of the missions of the center is to develop virtual
technology that eliminates the need for surgeries on
animals. We would like to expand into virtual surgery using
computer models with robotic instruments," says
Flint.

"It allows for the potential of operating at a great
distance," Flint says, noting that there are military
medicine possibilities, among others. "Emergency medicine
and the management of critical wounds could be potentially
performed in a MASH unit. And NASA could use the technology
to operate on someone during space travel."

Such instruments and procedures are still evolving (Brown,
looking to the future, says the current robot is the "Model
T" version). Among other drawbacks, there is the issue of
time delay in telesurgery. Whether phone lines or the
Internet is used, a partial second delay could cause the
surgeon to respond less quickly to bleeding.

And though the robot reduces hand fatigue during surgery,
the surgeon can't feel the response of the tissue he or she
is cutting or cauterizing -- what's known as "haptic"
feedback.

Each new medical advance, after all, brings benefits and
challenges. And that speaks to future endeavors at MISTC,
according to center directors. Brown hopes to bring in
simulators -- computer-based virtual surgical theaters
(sort of a souped-up version of car simulators once
routinely used in driver's ed courses). But that costs
money, and MISTC is currently seeking additional funding to
stay in business year to year. If the center and other R &
D labs are successful in this arena, traditional surgical
training methods -- many of which have been around for
centuries -- could eventually be phased out. "One of the
missions of the center is to develop virtual technology
that eliminates the need for surgeries on animals," says
Flint. "We would like to expand into virtual surgery using
computer models with robotic instruments."

Back in the MISTC lab, meanwhile, medical students who
might someday test such advances gather around Brown as he
finishes a perfect suture. They peer over each other's
shoulders before going back to try again. "There is a
Russian proverb," Brown is fond of saying. "Repetition is
the mother of learning."